Blue Choice Preferred PPO Bronze Plans

Our Rating:

Blue Choice Preferred PPO Bronze Plans offer a respectable PPO network of doctors and hospitals and the convenience of never needing a referral to see a specialist. Blue Choice Preferred PPO Plans are coupled with the Blue Choice Preferred PPO network, a smaller version of the “standard” Blue Cross Blue Shield of Illinois PPO network and the largest PPO network BCBSIL offers to individual health plans. If you can accept some reduced hospital and physician choice, a Blue Choice Preferred Bronze PPO plan may be a great option for you. Because the Bronze plans have the same out of pocket maximum as Gold and Silver plans in 2018, it is actually cheaper to purchase a Bronze plan than Gold or Silver if you had a catastrophic event or were hospitalized.

All Blue Choice Bronze plans offer the same set of essential health benefits, quality and amount of care.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 or other costs for services this plan covers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Common Medical Event

Services You May Need

Your cost if you usea ParticipatingProvider

Your cost if you usea Non-ParticipatingProvider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$40 copay 2x/year

50% coinsurance

No benefits will be provided for services which are not, in the reasonable judgment of Blue Cross and
Blue Shield, medically necessary

Specialist visit

50% coinsurance

50% coinsurance

—none—

Other practitioner office visit

50% coinsurance

50% coinsurance

Acupuncture not covered. Chiropractic and Osteopathic Manipulation are limited to 25 visits per calendar year.

Lower coinsurance applies at preferred
Participating pharmacies. Retail covers a 30 day supply and home delivery covers a 90 day supply. Certain women’s preventive services will be covered with no cost to the member.
For a full list of these prescriptions and/or services, please contact
Customer Service. Non-Participating home delivery is not covered.
Non-Participating specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. For Non-Participating drug provider, you are responsible for 50% of the eligible amount after the coinsurance. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Generic drugs are not subject to the deductible.

Abortions not covered, except where a pregnancy is the result of rape or incest, or for a pregnancy which, as
Certified by a physician, places the woman in danger of death unless an abortion is performed.

Physician/surgeon fees

$200/visit plus 50% coinsurance

50% coinsurance

If you need immediatemedical attention

Emergency room services

$1,000/visit plus 50% coinsurance

$1,000/visit plus 20% coinsurance

Copayment waived if admitted.

Emergency medical transportation

50% coinsurance

50% coinsurance

Ground and air transportation covered.

Urgent care

$15 copayment/visit

50% coinsurance

—none—

If you have a hospitalstay

Facility fee (e.g., hospital room)

$850/visit
plus 50% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Inpatient Services: Participating (Par),
member may be balance billed if preauthorization not received within
15 days prior. Non-Participating (Non-Par), $500 penalty if not preauthorized 2 business days prior.

Physician/surgeon fee

$200/visit plus 20% coinsurance

50% coinsurance

If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral health outpatient services

50% coinsurance

50% coinsurance

Copayment may apply. Pre-authorization is required for Psychological testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; and Intensive Outpatient Treatment. Inpatient Services: Par, member may be balance billed if preauthorization
not received within 15 days prior.
Non-Par, $500 penalty if not preauthorized 2 business days prior. Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not
preauthorized one business day prior.
Non-Par, $500 penalty if not
preauthorized one business day prior.

Mental/Behavioral health inpatient services

$850/visit
plus 50% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Substance use disorder outpatient services

50% coinsurance

50% coinsurance

Substance use disorder inpatient services

$850/visit
plus 50% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant

Childbirth/delivery professional services

50% coinsurance

50% coinsurance

Copyament applies to first prenatal
visit per pregnancy.

Childbirth/delivery facility services

$850/visit
plus 50% coinsurance

$1,500/visit plus 50%
coinsurance

–none—

If you need helprecovering or have other special health needs

Home health care

50% coinsurance

50% coinsurance

Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not preauthorized one business day prior.
Non-Par, $500 penalty if not preauthorized one business day prior.

Rehabilitation services

50% coinsurance

50% coinsurance

Habilitation services

50% coinsurance

50% coinsurance

Skilled nursing care

50% coinsurance

50% coinsurance

Durable medical equipment

50% coinsurance

50% coinsurance

Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service

50% coinsurance

50% coinsurance

Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.

If your child needsdental or eye care

Children’s Eye exam

No Charge

Not Covered

One visit per year. See benefit booklet for network details.

Children’s Glasses

No Charge

Not Covered

One pair of glasses per year.
See benefit booklet for network details.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 or other costs for services this plan covers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Common Medical Event

Services You May Need

Your cost if you usea ParticipatingProvider

Your cost if you usea Non-ParticipatingProvider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

40% coinsurance after ded.

50% coinsurance

No benefits will be provided for services which are not, in the reasonable judgment of Blue Cross and
Blue Shield, medically necessary

Specialist visit

40% coinsurance after deductible

50% coinsurance

—none—

Other practitioner office visit

50% coinsurance

50% coinsurance

Acupuncture not covered. Chiropractic and Osteopathic Manipulation are limited to 25 visits per calendar year.

Lower coinsurance applies at preferred
Participating pharmacies. Retail covers a 30 day supply and home delivery covers a 90 day supply. Certain women’s preventive services will be covered with no cost to the member.
For a full list of these prescriptions and/or services, please contact
Customer Service. Non-Participating home delivery is not covered.
Non-Participating specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. For Non-Participating drug provider, you are responsible for 50% of the eligible amount after the coinsurance. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Generic drugs are not subject to the deductible.

Abortions not covered, except where a pregnancy is the result of rape or incest, or for a pregnancy which, as
Certified by a physician, places the woman in danger of death unless an abortion is performed.

Physician/surgeon fees

$200/visit plus 50% coinsurance

50% coinsurance

If you need immediatemedical attention

Emergency room services

$1,000/visit plus 40% coinsurance

$1,000/visit plus 40% coinsurance

Copayment waived if admitted.

Emergency medical transportation

40% coinsurance

50% coinsurance

Ground and air transportation covered.

Urgent care

40% coinsurance

50% coinsurance

—none—

If you have a hospitalstay

Facility fee (e.g., hospital room)

$850/visit
plus 40% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Inpatient Services: Participating (Par),
member may be balance billed if preauthorization not received within
15 days prior. Non-Participating (Non-Par), $500 penalty if not preauthorized 2 business days prior.

Physician/surgeon fee

40% coinsurance

50% coinsurance

If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral health outpatient services

40% coinsurance

50% coinsurance

Copayment may apply. Pre-authorization is required for Psychological testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; and Intensive Outpatient Treatment. Inpatient Services: Par, member may be balance billed if preauthorization
not received within 15 days prior.
Non-Par, $500 penalty if not preauthorized 2 business days prior. Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not
preauthorized one business day prior.
Non-Par, $500 penalty if not
preauthorized one business day prior.

Mental/Behavioral health inpatient services

$850/visit
plus 40% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Substance use disorder outpatient services

50% coinsurance

50% coinsurance

Substance use disorder inpatient services

$850/visit
plus 50% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant

Childbirth/delivery professional services

50% coinsurance

50% coinsurance

Copayment applies to first prenatal
visit per pregnancy.

Childbirth/delivery facility services

$850/visit
plus 50% coinsurance

$1,500/visit plus 50%
coinsurance

–none—

If you need helprecovering or have other special health needs

Home health care

50% coinsurance

50% coinsurance

Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not preauthorized one business day prior.
Non-Par, $500 penalty if not preauthorized one business day prior.

Rehabilitation services

50% coinsurance

50% coinsurance

Habilitation services

50% coinsurance

50% coinsurance

Skilled nursing care

50% coinsurance

50% coinsurance

Durable medical equipment

50% coinsurance

50% coinsurance

Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service

50% coinsurance

50% coinsurance

Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.

If your child needsdental or eye care

Children’s Eye exam

No Charge

Not Covered

One visit per year. See benefit booklet for network details.

Children’s Glasses

No Charge

Not Covered

One pair of glasses per year.
See benefit booklet for network details.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page 2 or other costs for services this plan covers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Common Medical Event

Services You May Need

Your cost if you usea ParticipatingProvider

Your cost if you usea Non-ParticipatingProvider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

40% coinsurance after ded.

50% coinsurance

No benefits will be provided for services which are not, in the reasonable judgment of Blue Cross and
Blue Shield, medically necessary

Specialist visit

40% coinsurance after deductible

50% coinsurance

—none—

Other practitioner office visit

50% coinsurance

50% coinsurance

Acupuncture not covered. Chiropractic and Osteopathic Manipulation are limited to 25 visits per calendar year.

Lower coinsurance applies at preferred
Participating pharmacies. Retail covers a 30 day supply and home delivery covers a 90 day supply. Certain women’s preventive services will be covered with no cost to the member.
For a full list of these prescriptions and/or services, please contact
Customer Service. Non-Participating home delivery is not covered.
Non-Participating specialty drug coverage is limited to certain medications that are clarified in the prescription drug rider. For Non-Participating drug provider, you are responsible for 50% of the eligible amount after the coinsurance. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. Generic drugs are not subject to the deductible.

Abortions not covered, except where a pregnancy is the result of rape or incest, or for a pregnancy which, as
Certified by a physician, places the woman in danger of death unless an abortion is performed.

Physician/surgeon fees

$200/visit plus 50% coinsurance

50% coinsurance

If you need immediatemedical attention

Emergency room services

$1,000/visit plus 40% coinsurance

$1,000/visit plus 40% coinsurance

Copayment waived if admitted.

Emergency medical transportation

40% coinsurance

50% coinsurance

Ground and air transportation covered.

Urgent care

40% coinsurance

50% coinsurance

—none—

If you have a hospitalstay

Facility fee (e.g., hospital room)

$850/visit
plus 40% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Inpatient Services: Participating (Par),
member may be balance billed if preauthorization not received within
15 days prior. Non-Participating (Non-Par), $500 penalty if not preauthorized 2 business days prior.

Physician/surgeon fee

40% coinsurance

50% coinsurance

If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral health outpatient services

40% coinsurance

50% coinsurance

Copayment may apply. Pre-authorization is required for Psychological testing; Neuropsychological testing; Electroconvulsive therapy; Repetitive Transcranial magnetic Stimulation; and Intensive Outpatient Treatment. Inpatient Services: Par, member may be balance billed if preauthorization
not received within 15 days prior.
Non-Par, $500 penalty if not preauthorized 2 business days prior. Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not
preauthorized one business day prior.
Non-Par, $500 penalty if not
preauthorized one business day prior.

Mental/Behavioral health inpatient services

$850/visit
plus 40% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

Substance use disorder outpatient services

50% coinsurance

50% coinsurance

Substance use disorder inpatient services

$850/visit
plus 50% coinsurance

$1,500 copayment/
visit plus 50%
coinsurance

If you are pregnant

Childbirth/delivery professional services

50% coinsurance

50% coinsurance

Copayment applies to first prenatal
visit per pregnancy.

Childbirth/delivery facility services

$850/visit
plus 50% coinsurance

$1,500/visit plus 50%
coinsurance

–none—

If you need helprecovering or have other special health needs

Home health care

50% coinsurance

50% coinsurance

Inpatient Services: Par, member may
be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.
Outpatient Services: Par, member will be responsible for the first $1,000 or 50%, whichever is less, if not preauthorized one business day prior.
Non-Par, $500 penalty if not preauthorized one business day prior.

Rehabilitation services

50% coinsurance

50% coinsurance

Habilitation services

50% coinsurance

50% coinsurance

Skilled nursing care

50% coinsurance

50% coinsurance

Durable medical equipment

50% coinsurance

50% coinsurance

Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service

50% coinsurance

50% coinsurance

Inpatient Services: Par, member may be balance billed if preauthorization not received within 15 days prior. Non-Par, $500 penalty if not preauthorized 2 business days prior.

If your child needsdental or eye care

Children’s Eye exam

No Charge

Not Covered

One visit per year. See benefit booklet for network details.

Children’s Glasses

No Charge

Not Covered

One pair of glasses per year.
See benefit booklet for network details.